Staphylococcus aureus Bacteremia, Australia
Peter Collignon; Graeme R. Nimmo; Thomas
Gottlieb; Iain B. Gosbell
Emerg Infect Dis. 2005; 11 (4): 554-561. ©2005 Centers for Disease
Control and Prevention (CDC)
Abstract
and Introduction
Abstract
Staphylococcus aureus bacteremia (SAB) is
common and increasing worldwide. A retrospective review was undertaken
to quantify the number of cases, their place of acquisition, and the
proportions caused by methicillin-resistant S. aureus (MRSA) in 17
hospitals in Australia. Of 3,192 episodes, 1,571 (49%) were community
onset. MRSA caused 40% of hospital-onset episodes and 12% of
community-onset episodes. The median rate of SAB was 1.48/1,000
admissions (range 0.61-3.24; median rate for hospital-onset SAB was
0.7/1,000 and for community onset 0.8/1,000 admissions). Using these
rates, we estimate that ≈6,900 episodes of SAB occur annually in
Australia (35/100,000 population). SAB is common, and a substantial
proportion of cases may be preventable. The epidemiology is evolving,
with >10% of community-onset SAB now caused by MRSA. This is an
emerging infectious disease concern and is likely to impact on empiric
antimicrobial drug prescribing in suspected cases of SAB.
Introduction
Bacteremia caused by Staphylococcus aureus
continues to be a common problem worldwide. In the preantibiotic era,
most cases occurred in young patients without underlying disease. The
associated death rate was 82%.[1] Even with antimicrobial drug
treatment, death rates remain high; in a recent meta-analysis of 31
studies, estimates of death rates for methicillin-resistant strains (MRSA)
varied from 0.0% to 83.3% (median 34.2%), while those for methicillin-sensitive
strains (MSSA) varied from 3.6% to 51.7% (median 25.0%).[2] Many of
these infections are healthcare associated and thus are potentially
preventable.
Antimicrobial drug resistance in S. aureus
arose early after the development of antimicrobial agents and
continues to evolve. In Australia, hospital strains are frequently
methicillin resistant and resistant to several other antimicrobial
drugs.[3] This resistance limits the choice of potentially efficacious
agents and results in frequent use of glycopeptides, such as
vancomycin. The reliance on vancomycin causes difficulties because
vancomycin has been shown to be less effective than isoxazolyl
penicillins (e.g., flucloxacillin) in treating severe infections
caused by S. aureus .[4,5] This may be 1 explanation for the higher
death rate associated with bacteremia caused by MRSA, compared with
that caused by MSSA.[2,6] Although MRSA tends to be the bacterium
discussed most often in relation to healthcare-associated infections,
MSSA strains are responsible for the largest proportion of
hospital-acquired infections.[3]
S. aureus remains a common
cause of bloodstream infections of community onset. Increasing numbers
of these community-onset infections are being caused by MRSA. Some of
these infections may be caused by hospital strains carried into the
community by patients or healthcare workers, but others are caused by
true community strains in patients who have had no recent healthcare
contact.[7-9] These strains have emerged in many countries, including
Australia, New Zealand, the United States, Canada, France,
Switzerland, Greece, Denmark, Finland, Scotland, and the Netherlands.
They are susceptible to most or all non-_-lactam antimicrobial drugs,
are highly pyogenic, and are often associated with indigenous
populations.[10,11]
Although S. aureus is a
well-known major cause of bacteremia, population-based estimates of
its incidence are lacking. This study used hospital data to estimate
the incidence of S. aureus bacteremia in Australia. In addition, we
classified episodes on the basis of community or hospital onset and on
the basis of methicillin susceptibility.
Methods
S. aureus bacteremia data were obtained from microbiology departments
that prospectively collected information for >12 months on episodes of
laboratory-confirmed bacteremia for the hospitals they serviced from
January 1, 1999, to December 31, 2002. Information retrieved from
existing databases included the total number of episodes of community-
and hospital-onset bacteremia, the number of episodes of community-
and hospital-onset MRSA and MSSA bacteremia, the total number of
hospital separations (defined as completed hospital admissions), and
the mean length of stay. Multiple positive blood cultures in the same
patient within 14 days were considered a single episode. Episodes were
considered to have a hospital onset when the first positive blood
culture was collected >48 hours after admission to hospital. All other
infections were designated community onset (for example, day-only
dialysis related episodes were defined as community onset, as were
infections with their onset in nursing homes). Organism identification
and susceptibility testing were by standard methods. All these
laboratories participate in external quality assurance programs as
well as AGAR national surveys,[3,12] which have quality control
procedures to ensure these laboratories accurately detect methicillin
resistance. Published data were used for the details on the number of
hospital beds and separations for Australia and for the classification
of different types of hospitals.[13] The term separations, rather than
admissions, is used in the published data because hospital abstracts
for inpatient care are based on information gathered at the time of
discharge. We have used the more commonly applied term of admissions,
however, for these episodes.
In Australia, most
healthcare-associated MRSA is caused by 1 clone defined by multilocus
sequence type (ST) 239; this clone is characteristically resistant to
multiple antimicrobial agents, including gentamicin.[3,12] Most of the
remaining healthcare-associated infections are caused by a recently
introduced strain, ST22, which is indistinguishable from epidemic
MRSA-15 in the United Kingdom. It is invariably resistant to
ciprofloxacin.[12] Thus, in Australia, MRSA that is acquired in the
community and is sensitive to both ciprofloxacin and gentamicin is not
likely to be associated with healthcare facility acquisition. We used
this pattern as a surrogate marker for community acquisition of MRSA
without healthcare-associated risk factors.
Results
We detected 12,771 bloodstream infections in the 17 hospitals
participating in this study (12 principal referral metropolitan, 3
large metropolitan, 1 private hospital, and 1 medium-sized public
hospital, and 1 private hospital with 2,013,534 total separations; (Table
1 ). There were 3,192 episodes of S. aureus bacteremia identified
(i.e., 25% of the total true bloodstream infections). The median rate
of S. aureus bacteremia was higher in the principal referral
metropolitan hospitals (1.59/1000 admissions) than in large
metropolitan hospitals (1.3) or the private hospital (0.6). The range
varied from 0.60 to 3.24 (
Table 2 ). The median rate of community-onset bacteremia episodes
was 0.80/1000 admissions (range 0.11-0.99). The median rate of
hospital-onset bacteremia was 0.72 episodes/1,000 admissions (range
0.13-1.30). The median rate of hospital-onset MRSA episodes was
0.22/1,000 admissions (range 0-0.89). When expressed as MRSA episodes
per 1,000 occupied bed days (OBDs), the rates varied from 0 to 0.30
with a median rate of 0.08. If day-only cases are removed from the
denominator then the median rate was 0.10 per 1,000 OBDs (range
0-0.39).
Of these 3,192 SAB
episodes, 1,621 (51%) were of hospital onset, and 1,571 (49%) had
their onset in the community. Of those with a hospital onset, 40% were
MRSA in comparison to 12% with a community onset. Of all MRSA
bacteremia episodes, 23% had a community onset, and 77% had hospital
onset. Of the 193 community-onset episodes of MRSA that occurred, only
47 (24%) had a sensitivity pattern (sensitive to gentamicin and
ciprofloxacin) that suggests that they were community acquired.
When both MRSA and MSSA were considered, data were available for 560
community-onset SAB infections (but only from 4 hospitals). The
proportions of these episodes that were noninpatient,
healthcare-associated were 35%, 42%, 18% and 16%, respectively (from
hospitals A, D, E, and N). In those hospitals, the percentage of S.
aureus episodes that were healthcare associated overall (i.e., all
hospital-onset cases and those community-onset cases associated with
healthcare exposure) were 75%, 69%, 64%, and 36%, respectively.
Mortality data were
available for 526 patients from 2 hospitals. At hospital E, the
mortality rate at day 7 was 10% (27 of 267 patients). When a subgroup
of these patients at hospital E (52 patients) was followed for a
longer period (2001-2002), the mortality rate was 23% at 30 days and
35% at 6 months. For those 24 patients with a community-onset episode
of bacteremia that was not healthcare associated, mortality rates were
6% at day 7, 17% at 1 month, and 21% at 6 months, respectively. At
hospital H (259 patients), the mortality rate at 30 days was 19%. At
hospital H, the mean length of stay for those with SAB was 25.6 days
compared to 6.2 days in matched controls. The mean length of stay was
longer for MRSA infections (39.2 days) than for MSSA infections (23.3
days)
The rates of S. aureus
bacteremia in different hospital populations were used to estimate the
incidence for Australia. Using our median bacteremia rate for S.
aureus bacteremia in different types of public hospitals (1.27/1,000
admissions, range 0.68-3.24) and in private hospitals (0.6/1,000
admissions), we estimated ≈6,900 episodes per year nationally (range
3,826-20,658) or 35/100,000 per year (
Table 3 and
Table 4 ). Some data are available from other countries for
comparison; the lowest annual rates are in Northern Ireland
(23/100,000) and the highest in the United States (56/100,000;
Table 4 ). However only 2 countries, Denmark and England, appeared
to have comprehensive collection systems, and their rates were
29/100,000 and 37/100,000, respectively.[17,20,22]
Discussion
S. aureus bacteremia is very common.
Approximately one fourth (26%) of all S. aureus bacteremia episodes
were caused by MRSA, and, as expected, the onset of most of these
episodes was in hospitals (77%). Notably, however, 12% of all
community-onset S. aureus infections were MRSA, which was 23% of all
MRSA bloodstream infection episodes. A recent study from the United
States similarly showed that 15% of community-onset SAB episodes were
MRSA.[14] Most of the community-onset strains in our study were
multiresistant or phenotypically consistent with UK EMRSA-15[15] and
thus most likely to have been acquired by patients who had previous
hospital contact, with nursing home contact a major factor in at least
1 of the hospitals in this study (hospital G). However, approximately
one fourth of these community-onset MRSA infections were caused by
other phenotypes of non-multiresistant MRSA and thus more likely to be
true community-acquired episodes of MRSA bacteremia. Severe cases of
MRSA bacteremia not associated with prior healthcare contact have been
reported previously in Australia.[7,9,16]
Use of the >48 hours
postadmission definition of hospital onset underestimates the number
of episodes of bacteremia that are healthcare associated. Many
patients with chronic conditions are now treated in the community or
on a day-only basis. Vascular lines are increasingly used in the
community and outpatient settings, providing a potential source of
bacteremia. The collection of data on the true association of episodes
of bacteremia to health care is time-consuming and was not done by
most institutions participating in this study. However, 3 principal
referral hospitals (hospitals A, D, and E) did collect these data for
971 episodes, and 64%-75% of their total S. aureus bacteremia episodes
were healthcare associated. Only 46%-61% of the episodes were acquired
while the patient was an inpatient (i.e., >48 h in hospital). This
finding means that in these larger hospitals approximately one third
of healthcare-associated episodes were acquired by either outpatients
or short-stay patients. These episodes are better defined as "noninpatient,
healthcare-associated." In a recent study in the United States, 62% of
their community-onset SAB infections were healthcare related (with
intravenous [IV] catheters the most common clinically apparent site of
infection).[14] On the basis of our data, we conclude that in
Australia approximately two thirds of all SAB episodes were associated
with healthcare or medical procedures (i.e., all hospital-onset and
approximately one third of community-onset episodes). A similar
situation is evident in Denmark[17] where in 2002, at least 59% of all
S. aureus infections were associated with healthcare procedures.
Clearly, substantial scope exists internationally for interventions in
healthcare settings to decrease the numbers of these episodes
(especially those related to IV catheters). Interventions to reduce S.
aureus bacteremia need to target healthcare-associated infections in
the broadest sense and include those following non-inpatient-related
medical procedures.
Community-onset infections
that have no healthcare association are also common and associated
with a high death rate (17% and 19% at hospitals E and H at 1 month,
respectively). How best to intervene to decrease these infections is
difficult to determine. Vaccination is a possibility for the future; a
recent trial of a conjugated capsular polysaccharide vaccine in renal
dialysis patients estimated efficacy at ≈60%.[18] However, vaccination
for the general population is unlikely to be available soon. We should
therefore concentrate on reducing the number of deaths from
established infections. Because the mortality rate associated with
community-acquired bacteremia increases with inadequate empiric
therapy,[19] all efforts should be made to promote compliance with
published guidelines for treatment of severe staphylococcal sepsis,
including adequate duration of therapy.
Available data suggest
that staphylococcal bacteremia is a major global health problem. The
median death rate for MSSA infections is 25%, and for MRSA infections,
34%.[20] Thus, >1,700 deaths in Australia are likely associated with
S. aureus bacteremia per year (assuming 6,900 episodes or a bacteremia
rate of 35/100,000/year). This estimate of the rate of SAB is similar
to England[20,22] but much lower than in the United States on the
basis of the rate derived from the figures available in the only
comparative study (55/100,000).[14] Our estimated rate in Australia is
higher than that in Denmark.[17,21] It is also higher that those
reported from Wales[22] and Ireland[23] (
Table 4 ); however, all episodes from these last 2 countries
likely were not reported in their voluntary reporting schemes. England
changed recently from a similar voluntary reporting scheme to a
compulsory scheme, and the numbers of reported episodes increased by
almost 50%.[24]
The rate of MRSA
bacteremia in England was higher per 1,000 OBDs than in our figures
from Australia (0.17 compared to 0.10 episodes per 1,000 OBDs,
respectively). MRSA was a substantial cause of episodes of SAB in this
study (26%). However, this percentage was lower than that seen in most
other countries (e.g., Wales, 47%;
Table 4 ) with the notable exception of Denmark (0.6% in
2002).[17]
We may have overestimated
the number of cases of bacteremia occurring in Australia because of
the overrepresentation of larger hospitals in our survey. However,
these hospitals participated because they had in place surveillance
systems for measuring all episodes of bacteremia. The rates of SAB may
have been relatively lower in these hospitals because they were also
more likely than were hospitals without surveillance systems to have
infection control programs in place to try to decrease the numbers of
these episodes. If systems were in place that better captured and
reported on all bacteremia episodes in well-defined populations (e.g.,
all of Australia or a state), then this would give a more accurate
rate. Such systems appear only to be in place in Denmark and
England.[17,21,24] Currently, no such systems are operating in
Australia. Limited data are available from a voluntary surveillance
system in Victoria[25] that captures an estimated two thirds of
bacteremic episodes that occur in that state. The extrapolated rate
(27 episodes/100,000 persons/year;
Table 4 ) was slightly lower than what we estimated for all of
Australia in this study.
Substantial illness and
increased medical costs are also associated with staphylococcal
bacteremia. S. aureus bacteremia is often related to serious
infections, including endocarditis, osteomyelitis, and septic
arthritis. It frequently results in prolonged hospital admission and
increased costs. In hospital H, the average length of stay for
patients with S. aureus bacteremia was 26.5 days. In South Australia,
the estimated additional cost of each episode of hospital-acquired S.
aureus infection was $22,000 in 1998.[26] Nationally, these South
Australian costs translate to additional hospital costs of ≈$150
million dollars ($22,000 x 6,900 episodes).
Treatment of S. aureus infections is complicated by the high
prevalence of antimicrobial drug resistance. Although this has long
been the case with multiresistant strains of MRSA in hospitals, the
spread of hospital strains into the community, as well as the
emergence of unique strains of MRSA unrelated to health care, have
made this an issue of general importance. At least 3 community strains
of MRSA are currently circulating in Australia.[10,27,28] Two of these
3 community strains carry the gene for Panton-Valentine leukocidin,
which is associated with subcutaneous abscess formation and
necrotizing pneumonia. A number of reports have already highlighted
the clinical impact of infection due to these strains.[9,28-30]
Surveillance data show that their prevalence is increasing in our
capital cities, but the situation in rural Australia is not well
documented.[3] This increase will inevitably affect guidelines for
empirical antimicrobial drug prescribing for staphylococcal infections
and for patients in the community with suspected SAB. Further
surveillance of staphylococcal infections, including bacteremia, is
warranted to guide recommendations for empirical therapy and infection
control interventions.
Table 1. Bacteremia
Episodes at Individual Hospitals*
|
|
A
|
B
|
C
|
D
|
E
|
F
|
G
|
H
|
I
|
|
a
|
a
|
a
|
a
|
a
|
a
|
a
|
a
|
a
|
Beds |
723
|
587
|
551
|
525
|
504
|
468
|
455
|
394
|
391
|
Years
studied |
4
|
4
|
3
|
4
|
4
|
3
|
4
|
4
|
2
|
Admissions over study
period |
256,251
|
203,130
|
150,502
|
204,116
|
194,246
|
132,781
|
185,680
|
175,583
|
67,855
|
Admissions >24 h over study period |
66,035
|
76,147
|
49,501
|
102,361
|
60,498
|
42,515
|
39,758
|
44,502
|
47,406
|
Mean length of stay
(day cases included) |
3.85
|
3.48
|
3.84
|
3.6
|
3.43
|
3.8
|
3.61
|
3.32
|
4.25
|
OBDs
(including day-only patients) |
986,566 |
706,892 |
577,928 |
781,235 |
666,264 |
504,568 |
670,305 |
582,936 |
288,384 |
OBDs (excluding
day-only patients) |
796,350 |
579,909 |
476,927 |
679,481 |
532,516 |
414,302 |
524,383 |
451,855 |
267,935 |
Total
S. aureus
bacteremia |
331
|
365
|
333
|
373
|
267
|
107
|
426
|
259
|
115
|
Total BSIs over study
period (all orgs) |
1,531
|
1,172
|
1,294
|
1,546
|
196
|
605
|
1,689
|
1,120
|
472
|
Total
BSI rate per hosp admissions (x1,000) |
5.97
|
5.76
|
8.60
|
7.57
|
6.67
|
4.50
|
9.01
|
6.38
|
6.95
|
|
|
|
|
L
|
M
|
N
|
O
|
P
|
Q
|
Total
|
ClassificationÝ |
a
|
a
|
a
|
b
|
b
|
b
|
c
|
d
|
-
|
Beds |
368
|
297
|
276
|
199
|
170
|
162
|
72
|
52
|
6,194
|
Years
studied |
4
|
2
|
4
|
4
|
4
|
4
|
4
|
4
|
-
|
Admissions over study
period |
104,534
|
58,549
|
92,114
|
64,311
|
41,690
|
48,900
|
18,223
|
15,069
|
2,013,534
|
Admissions >24 h over study period |
50,018
|
25,617
|
36,322
|
31,259
|
10,556
|
31,681
|
13,055
|
2,894
|
730,125
|
Mean length of stay
(day cases included) |
4.1
|
4.49
|
3.06
|
3.37
|
5.4
|
3.60
|
5.10
|
2.88
|
-
|
OBDs
(including day-only patients) |
428,589
|
262,592
|
281,869
|
216,728
|
225,126
|
176,040
|
92,937
|
43,399
|
7,491,240
|
OBDs (excluding
day-only patients) |
374,073
|
229,660
|
226,077
|
183,676
|
192,874
|
158,821
|
87,769
|
31,224
|
6,207,832
|
Total S. aureus
bacteremia |
155
|
123
|
72
|
44
|
135
|
62
|
11
|
14
|
3,192
|
Total
BSIs over study period (all orgs) |
653
|
338
|
351
|
282
|
881
|
274
|
67
|
63
|
12,771
|
Total
BSI rate per hosp admissions (x1,000) |
6.25
|
5.77
|
3.81
|
4.39
|
21.13
|
5.60
|
3.68
|
4.18
|
-
|
*MSSA, methicillin-susceptible
Staphylococcus aureus ; MRSA, methicillin-resistant S. aureus
; OBDs, occupied bed days; BSI, bloodstream infection; orgs,
microorganisms.
Hospital classification: a, principal referral: metropolitan (>20,000
acute weighted separations per year) and rural (>16,000 acute weighted
separations); b, large metropolitan (>10,000 acute weighted
separations); c, private hospital; d, medium sized (metropolitan and
rural 2,000 acute or acute weighted to 5,000 acute weighted
separations).
1999-2002.
1999-2001.
1999-2000.
Table 2. Rates of Staphylococcus aureus
Bacteremia (SAB) at Individual Hospitals
|
Hospital
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S. aureus bacteremia (SAB) |
|
365 |
333 |
373 |
267 |
107 |
426 |
259 |
115 |
155 |
123 |
72 |
44 |
135 |
62 |
11 |
14 |
Rate/hospital admissions (x1,000) |
1.29 |
1.80 |
2.21 |
1.83 |
1.37 |
0.80 |
2.29 |
1.48 |
1.69 |
1.48 |
2.10 |
0.78 |
0.68 |
3.24 |
1.27 |
0.60 |
0.93 |
Rate of community-onset infections* |
0.51 |
0.74 |
0.94 |
0.99 |
0.66 |
0.35 |
0.99 |
0.83 |
0.77 |
0.88 |
1.06 |
0.58 |
0.48 |
2.40 |
0.80 |
0.11 |
0.80 |
Rate of hospital-onset S. aureus
infection* |
0.78 |
1.05 |
1.27 |
0.84 |
0.72 |
0.46 |
1.30 |
0.65 |
0.93 |
0.60 |
1.04 |
0.21 |
0.20 |
0.84 |
0.47 |
0.49 |
0.13 |
Rate of hospital-onset MSSA * |
0.54 |
0.58 |
0.74 |
0.64 |
0.46 |
0.42 |
0.41 |
0.55 |
0.49 |
0.25 |
0.59 |
0.10 |
0.08 |
0.62 |
0.41 |
0.44 |
0.13 |
Rate of hospital-onset MRSA* |
0.24 |
0.48 |
0.53 |
0.20 |
0.26 |
0.04 |
0.89 |
0.10 |
0.44 |
0.35 |
0.44 |
0.11 |
0.12 |
0.22 |
0.06 |
0.05 |
0.00 |
Rate of S. aureus
SAB sepsis/1000 OBDs |
0.34 |
0.52 |
0.58 |
0.48 |
0.40 |
0.21 |
0.64 |
0.44 |
0.40 |
0.36 |
0.47 |
0.26 |
0.20 |
0.60 |
0.35 |
0.12 |
0.32 |
MRSA SAB rate/1,000
OBDs |
0.08 |
0.17 |
0.18 |
0.08 |
0.09 |
0.01 |
0.30 |
0.05 |
0.14 |
0.15 |
0.13 |
0.05 |
0.05 |
0.06 |
0.02 |
0.01 |
0.00 |
MRSA SAB rate/1,000 OBDs- excluding 1 day only |
0.10 |
0.21 |
0.22 |
0.09 |
0.11 |
0.01 |
0.39 |
0.06 |
0.15 |
0.17 |
0.15 |
0.06 |
0.05 |
0.07 |
0.03 |
0.01 |
0.00 |
*SAB per hospital admissions (x1,000).
ÝOBDs, occupied bed days; MSSA, methicillin-susceptible
S. aureus ; MRSA, methicillin-resistant S. aureus .
Table 3. Estimated
Numbers of Staphylococcus aureus Bacteremia, Australia*
|
Principal
referral public hospitals
|
Large public
hospitals
|
Medium public
hospitals
|
Small acute-care
public hospitalsÝ
|
Other public
hospitalsý
|
Total acute-care
public hospitals§
|
Total private
|
Total
Australia-wide (based on tally of public and private hospitals)
|
Published data for
Australia 2001-2002[13] |
Number of hospitals
|
66
|
40
|
103
|
134
|
381
|
724
|
537¶
|
1,306
|
No. of beds
|
27,258
|
5,760
|
6,386
|
3,216
|
6,384
|
49,004
|
27,407
|
75,516
|
Total admissions
(x1,000)
|
2,585
|
561
|
486
|
153
|
165
|
3,950
|
2,426
|
6,376
|
Same day separations
(x1,000)
|
-
|
-
|
-
|
-
|
-
|
1,886
|
1,453
|
-
|
Average length of
stay
|
3.8
|
3.6
|
3.4
|
-
|
-
|
4.1
|
2.9
|
3.5
|
S. aureus BSI
episodes (calculated rates from data in this study)
|
S. aureus
BSI rate/1,000 admissions
|
0.81-2.29
|
0.68-3.24
|
0.93
|
0.6
|
0.6
|
0.68-3.24
|
0.6
|
0.6-3.24
|
Estimated episodes/y
|
2,094-5,920
|
381-1,818
|
452
|
92
|
99
|
2,370-12,798
|
1,456
|
3,826-20,658
|
Median rate/1,000
admissions
|
1.59
|
1.27
|
0.93
|
0.6
|
0.6
|
1.37
|
0.6
|
NA
|
Estimated episodes/y
(based on median)
|
|
|
|
|
|
5,412
|
1,456
|
6,867
|
Hospital-onset MSSA
|
Rate/1,000
admissions
|
0.10-0.74
|
0.08-0.62
|
0.13
|
0.13
|
0.13
|
0.08-0.74
|
0.44
|
0.10-0.97
|
Estimated episodes/y
|
259-1,913
|
45-347
|
31
|
137
|
21
|
316-2,923
|
1,067
|
638-4,718
|
Median rate/1,000
admissions
|
0.51
|
0.41
|
0.13
|
0.13
|
0
|
0.47
|
0.44
|
NA
|
Estimated episodes/y
(based on median)
|
1,318
|
230
|
63
|
137
|
21
|
1,769
|
1, 067
|
2 836
|
Hospital-onset MRSA
|
Rate/1,000
admissions
|
0.04-0.89
|
0.06-0.22
|
0
|
0
|
0
|
0.05-0.89
|
0.05
|
0.05-0.89
|
Estimated episodes/y
|
103-2,301
|
34-123
|
0
|
0
|
0
|
198-3,516
|
121
|
255-5,675
|
Median rate/1,000
admissions
|
0.31
|
0.12
|
0
|
0
|
0
|
0.25
|
0.05
|
NA
|
Estimated episodes/y
(based on median)
|
801
|
67
|
0
|
0
|
0
|
868
|
121
|
1.015
|
*BSIs,
bloodstream infections; MSSA, methicillin-susceptible S. aureus
; MRSA, methicillin-resistant S. aureus ; NA, not applicable.
No data from this study on smaller public
hospitals. Therefore the assumed rate of sepsis is for lowest in other
groups (i.e., private hospitals).
These public hospitals were those without case mix-adjusted admissions
data and also non-acute small hospitals. The assumed rate of sepsis is
for lowest in other groups (i.e., private hospitals).
Table 4. International Rates and Numbers of
Staphylococcus aureus Bacteremia (SAB)*
Country
|
Y
|
Population
|
SAB/y
|
SAB/105/y
|
% MRSA
|
Australia |
Present report |
1998-2002 |
19,500,000 |
6,900 |
35 |
27 |
Victoria[25]Ý |
1990-1999 |
4,502,000 |
804 |
27 |
28 |
Denmark |
Northern Jutland[21] |
1996-1998 |
493,000 |
155 |
31 |
ND |
Whole of Denmark[17]ý |
2002 |
5,350,000 |
1,488 |
28 |
0.6 |
Ireland[23]§ |
1999 |
3,700,000 |
ND* |
25 |
36 |
United Kingdom |
England20,22¶ |
2002-2003
2003 |
49,200,000 |
18,403
19,244 |
37
39 |
40
41 |
Northern Ireland[22,24]# |
2002
2003 |
1,697,000 |
397
569 |
23
34 |
38
44 |
Wales[22]# |
2003 |
2,920,000 |
742 |
25 |
47 |
USA |
Connecticut[14]** |
1998 |
1,124,337 |
634 |
56 |
ND* |
*MRSA, methicillin-resistant
Staphylococcus aureus ; ND, no data given.
ÝIn Victoria, 8,036 SAB episodes were reported, resulting
in a rate of 17.8/100,000. The final rate (27.0) for the entire state
was extrapolated from this figure. The Victorian scheme is estimated
to capture about two thirds of all bacteremia episodes that occur in
that state per year.
ýSystem in place in Denmark since 1960, with numbers of
episodes continually rising (e.g., in 1966, 400 per year and total
population 4.8 million or 8/100,000). Collection data based on
reviewing all discharge summaries and laboratory samples (15 of 16
counties). Associated 23% mortality rate in 2002, and 22% of these
deaths were directly related to sepsis.
§Rates in different regions varied from 8.9 to 37.1 per
100,000. Likely underreporting.[22]
¶Compulsory reporting system. Unclear if all community
onset episodes were included. In England, underreporting occurred with
a voluntary system (only 13,770 episodes reported for 2003; thus, a
50% increase with compulsory system).[22]
#This rate is based on voluntary reporting system. Real
rate might be 50% higher.[22,24]
**Retrospective case analysis. Rate increased with age, urban areas,
and African American ethnicity. 15% of community-onset SAB episodes
were MRSA.
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|